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Inevitable Cesarean Myomectomy Following Delivery Through Posterior Hysterotomy in a Case of Uterine Torsion DOI: 10.5455/medarh.2013.67.75-76 Med Arh. 2013 Feb; 67(1): 75-76 Received: October12th 2012 | Accepted: December 19th 2012 CONFLICT OF INTEREST: NONE DECLARED case report Inevitable Cesarean Myomectomy Following Delivery Through Posterior Hysterotomy in a Case of Uterine Torsion Radmila Sparic¹, Biljana Lazovic² Clinic for Gynaecology and Obstetrics, Clinical Center of Serbia, Belgra
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  75 Med Arh. 2013 Feb; 67(1): 75-76 ã CASE REPORT Inevitable Cesarean Myomectomy Following Delivery Through Posterior Hysterotomy in a Case of Uterine Torsion DOI: 10.5455/medarh.2013.67.75-76Med Arh. 2013 Feb; 67(1): 75-76 Received: October12th 2012 | Accepted: December 19th 2012 CONFLICT OF INTEREST: NONE DECLARED CASE REPORT  Inevitable Cesarean Myomectomy Following Delivery Through Posterior Hysterotomy in a Case of Uterine Torsion Radmila Sparic¹,   Biljana Lazovic²Clinic for Gynaecology and Obstetrics, Clinical Center of Serbia, Belgrade, Serbia 1 Clinical Hospital Center Zemun–Belgrade, Internal Medicine Clinic, Belgrade, Serbia 2 B ackground:  orsion of the pregnant uterus at term is a very infrequent obstetric event. It is usually associated with the presence of myoma or congenital deformities. Maternal prognosis is good after surgical treatment; however, prenatal mortality is high. Case report:  We report a case of posterior low transverse hysterectomy in a case of uterine torsion at 38 weeks’ gestation, due to a large myoma. At presentation, her cervix was unfavorable and cardiotocography showed spontaneous deceleration demanding delivery by cesarean section. Following delivery, it was realized that the incision had been made on the posterior wall of the uterus and that the uterus was axially rotated by 180 degrees. Te mother recovered uneventfully and both mother and the baby were discharged on the fifth postoperative day. Conclusion:  Obstetricians must have uterine torsion in mind when performing a cesarean section in patients with myomas. Key words: uterine torsion, pregnancy, cesarean section, myoma. Corresponding author: Biljana Lazovic, MD. Clinical Hospital Center Zemun-Belgrade, Internal Medicine Clinic 11080 Belgrade, Serbia. Tel: 062212040. E-mail: lazovic.biljana@gmail.com 1. INTRODUCTION Uterine torsion is a rotation of more than 45 degrees of the uterus around its longitudinal axis that occurs at the  junction between the cervix and the corpus of the uterus. Te extent of the torsion is usually 180 degrees, although it has been described torsion from 60 to 720 degrees (1). It is infrequent in hu-mans, and majority of the available pa-pers are case reports diagnosed as inci-dental findings during surgical explora-tion (2, 3). Uterine torsion was first de-scribed by an Italian veterinary surgeon in 1662 (3). Most reported reviews are from the veterinary literature, particu-larly in the cattle (4). Te most extensive review was published by Jensen, includ-ing 212 reported cases (1). Te cause of the uterine torsion during pregnancy is unclear. Te earliest reported age for uterine torsion during pregnancy is in the sixth gestational week and the latest in forty third weeks (1). It is associated with the presence of uterine myomas or congenital deformities, abnormal fe-tal presentations, placenta praevia, pel- vic tumors or abnormalities, although there are cases in which none of the predisposing factors were present (2, 3). Clinical diagnosis is difficult, since it is rarely considered and symptoms are ei-ther absent or nonspecific (abdominal pain, vaginal bleeding, shock, cervical dystocia, painful uterine contractions, dynamic hypertonia, repeated episodes of pathological CG patterns, urinary and intestinal symptoms) (1, 6).Te diagnosis is often missed, usu-ally made at laparotomy (2, 3). Mater-nal prognosis is good after surgical treatment; however, prenatal mortal-ity is high (6). 2. CASE REPORT A 28-year-old nullipara with a di-agnosed uterine myoma was referred to our hospital at 38 weeks’ gesta-tion. Her prenatal course was uncom-plicated. On vaginal examination the cervix was closed and 2 centimeters long. Cardiotocography showed decel-erations demanding delivery by cesar-ean section. During surgery, the utero- vesical fold of peritoneum could not be found over the lower segment. As it was not possible to perform torsion of the gravid uterus, a low transverse in-cision was made and a 3150 gram baby was delivered easily with a 1-minute Apgar score 7.Following delivery, it was realized that the incision had been made on the posterior wall of the uterus and that the uterus was axially rotated by 180 degrees. Detorsioning was carried out by exteriorizing the myoma and the uterus out of the abdominal cavity. Te uterus was closed in two layers with a continuous stitch. A 15 cm intramural myoma on the right fundal region was found. A standard technique for myo-  76 Med Arh. 2013 Feb; 67(1): 75-76 ã CASE REPORT Inevitable Cesarean Myomectomy Following Delivery Through Posterior Hysterotomy in a Case of Uterine Torsion mectomy was used with no compli-cations. Following myomectomy, the uterus was put back into abdomen in its anatomical position. Te mother re-covered uneventfully and both mother and the baby were discharged on the fifth postoperative day. At a follow up examination six weeks later, her pelvic examination was normal. 3. DISCUSSION Except pathological cardiotocogra-phy, our case was clinically asymptom-atic for uterine torsion. Tis is consis-tent with the Jensen’s report that in 11% of the patients no symptoms are pres-ent (1). Te clinical presentation of uter-ine torsion is variable and physical ex-amination and ultrasonographic scan-ning may be insufficient for diagno-sis (1). Vaginal examination, as in our case, only reveals the cervical canal to be twisted and closed. Ultrasound has some diagnostic role in cases of regu-lar pregnancy follow up, when chang-ing in placental localization on ultra-sound could be a sign of uterine tor-sion (7). Magnetic resonance imaging is currently the method of choice for establishing diagnosis by demonstra-tion of an X shaped configuration of the torsion site (8, 9). Tus, this kind of pregnancy complication could be often misdiagnosed in cases insufficient pre-natal care or inaccessibility of modern diagnostic tools, such as magnetic res-onance imaging. Rare affection of diffi-cult clinical diagnosis, the uterine tor-sion presents both diagnostic and ther-apeutic dilemma. Once the diagnosis is established, immediate surgical inter- vention is advisable. Delayed surgical intervention could result in increased maternal morbidity and poor fetal out-come, even fetal demise.Te cause of uterine torsion is usu-ally due to an anatomical aberration with myomas being the most common (1, 6, 7). Myomas are observed more frequently in pregnancy because more women are delaying childbearing. Also, there is a high incidence of cesarean section in women with myomas with a large proportion being directly related to the myoma (8). Unlike the torsion described during labor, that occurring during pregnancy might be difficult to recognize. Uterine torsion signs, when present are not specific. Our case was clinically asymptomatic for uterine tor-sion. Tis is consistent with the Jen-sen’s report that in 11% of the patients no symptoms are present (1). Delivery is either by posterior hysterectomy fol-lowed by repositioning of the uterus or by repositioning of the uterus first be-fore lower segment cesarean section. Once the diagnosis is established, im-mediate surgical intervention is ad- visable. Delayed surgical intervention could result in increased maternal mor-bidity and poor fetal outcome, even in-trauterine fetal demise (9). Important current concept of management in-cludes cesarean section for parturient with this infrequent pregnancy compli-cation. Te same treatment is advisable in all the other cases with viable fetus. Te alternative hysterectomy incision could be performed transversal through posterior uterine wall, above the level of uterosacral ligaments, in cases of failed uterine detorsion efforts such in our case. Following closure of the uterine incision the contracted uterus should be rotated back to the correct anatom-ical position. In all the cases of uterine torsion it is advisable to conduct ad- junct surgery to eliminate the possible etiologic factors. Tere are some au-thors who suggest bilateral plication of the round ligaments as a prophylactic procedure to provide uterine stability, thus preventing the recurrence of the torsion (10). Te effectiveness of this method requires further investigation, considering that exact etiopathogenesis of uterine torsion in pregnancy remains open to speculation. Despite the fact that the predisposing factors are rela-tively common, such as myomas, tor-sion of the uterus is rare. ogether with the fact that in 16% of cases no abnor-malities could be found, this data sug-gests that some additional, yet incom-pletely recognized factors need be pres-ent for uterine torsion to occur (11, 12).In cases with uterine torsion prior to fetal viability, the treatment should be individualized. Uterine detorsion is the principal treatment, followed by re-moval of contributing factors, if possi-ble. Tere are not sufficient data in the literature to define the safety of leav-ing the pregnancy to continue. Once again, if the effectiveness of shortening of round ligaments gets proven, con-tinuing of the pregnancy in such cases might be advisable in the future (13). 4. CONCLUSION Te cause of uterine torsion is usu-ally due to an anatomical aberration with myomas being the most common. Myomas are observed more frequently in pregnancy because more women are delaying childbearing. Also, there is a high incidence of cesarean section in women with myomas with a large pro-portion being directly related to the my-oma. Although uterine torsion is rare, obstetricians must have this complica-tion in mind when performing a cesar-ean section in patients with myomas. In conclusion, during cesarean delivery in such patients obstetricians should rou-tinely palpate for uterine rotation be-fore incision is made into the lower seg-ment. Anatomical landmarks should be identified prior to uterine incision thus checking for torsion of the uterus in pa-tients with myomas. An inappropriate uterine incision to deliver the fetus may cause vascular and ureteric injury, caus-ing serious complications. REFERENCES 1. Jensen JG. Uterine torsion in pregnancy. Acta Obstet Gy-necol Scand. 1992; 71(4): 260-265.2. Bukar M, Moruppa JY, Ehalaiye B, Ndonya DN.Uterine torsion in pregnancy. J Obstet Gynaecol. 2012; 32(8): 805-806.3. Kim SK, Chung JE, Bai SW, Kim JY, Kwon HK, Park KH. et al. orsion of the pregnant uterus. Yonsei Med J. 2001; 42(2): 267-269.4. Oláh KS. Uterine torsion and ischaemia of one horn of a bicornuate uterus: a rare cause of failed second trimes-ter termination of pregnancy. BJOG. 2002; 109: 585-586..5. Frazer GS. Perkins NR. Constable PD. Bovine uterine torsion: 164 hospital referral cases. heriogenology. 1996; 46: 739-758.6. Sparic R, Pervulov M, Stefanovic A, adic J, Gojnic M, Milicevic S, et al. Uterine torsion in term pregnancy. Srp arh Celok Lek. 2007; 135(9-10): 572-575.7. Cicchiello LA, Hamper UM, Scoutt LM. Ultrasound eval-uation of gynecologic causes of pelvic pain. Obstet Gy-necol Clin North Am. 2011; 38(1): 85-114.8. Nicholson WK, Coulson CC, McCoy MC. Semelka RC. Pelvic magnetic resonance imaging in the evaluation of uterine torsion. Obstet Gynecol. 1995; 85: 888-890.9. Masselli G, Brunelli R, Casciani E, Polettini E, Bertini L, Laghi F, Anceschi M, Gualdi G Acute abdominal and pel- vic pain in pregnancy: MR imaging as a valuable adjunct to ultrasound? Abdom Imaging. 2011; 36(5): 596-603.10. Duplantier N. Begneaud W. Wood R. Dabezies C. orsion of a gravid uterus associated with maternal trauma: a case report. J Reprod Med. 2002; 47: 683-685.11. Pelosi MA III. Pelosi MA. Managing extreme uterine torsion at term. A case report. J Reprod Med. 1998; 43: 153-157.12. Foissac R, Sautot-Vial N, Birtwisle L, Bernard JL, Fon-taine A, Boujenah S, Benchimol D, Bereder JM. orsion of a huge pedunculated uterine leiomyoma. Am J Surg. 2011; 201(6): e43-5.13. Albayrak M, Benian A, Ozdemir I, Demiraran Y, Gu-ralp O. Deliberate posterior low transverse incision at cesarean section of a gravid uterus in 180 degree of tor-sion: a case report. J Reprod Med. 2011; 56(3-4): 181-183..  Copyright of Medicinski Arhiv is the property of Avicena D.O.O. Sarajevo and its content may not be copied oremailed to multiple sites or posted to a listserv without the copyright holder's express written permission.However, users may print, download, or email articles for individual use.
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